A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?

A. Temperature of 38°C (100.4°F):A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.

B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.

C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.

D. Receiving prednisone for nephrotic syndrome:Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR

A. Obtain a daily weight:

This is an appropriate action. Monitoring daily weights can help assess fluid balance and detect fluid retention, which is common in children with kidney disorders like acute glomerulonephritis. Sudden weight gain or fluid overload may indicate worsening kidney function and the need for intervention.

B. Strain the urine:

Straining the urine may be indicated to monitor for the presence of blood or protein, which are common findings in acute glomerulonephritis. Straining the urine is not necessary, as hematuria is a common finding and does not indicate kidney damage.

C. Monitor blood glucose level every 4 hr:

Monitoring blood glucose levels every 4 hours is not directly related to the care of a child with acute glomerulonephritis. Blood glucose monitoring is more relevant in conditions such as diabetes mellitus. However, monitoring electrolyte levels, including blood glucose, may be part of routine laboratory testing in children with kidney disorders.

D. Recommend strict bed rest:

Strict bed rest is not typically recommended for children with acute glomerulonephritis unless there are specific complications or severe symptoms requiring immobilization. While some activity restriction may be recommended during the acute phase of the illness, strict bed rest may lead to complications such as deconditioning and venous thromboembolism.